Knowledge, attitudes, and practices towards COVID-19 among undergraduates during emergency remote learning

Background The coronavirus disease 2019 (COVID-19) pandemic paralyzes the education sector. To minimize the interruption of teaching and learning, most universities in Malaysia shifted to virtual mode during this unprecedented period of the pandemic. With an ever-increasing number of Malaysians fully vaccinated against COVID-19, the education system is expected to switch back to face-to-face mode this year. It is crucial to assess the knowledge, attitudes, and practices (KAP) of COVID-19 among emergency remote learning undergraduates before reverting to physical teaching and learning. Hence, a study was conducted with this aim in mind. Methods A total of 299 Malaysian undergraduates were recruited through a snowball sampling approach. The online questionnaire encompassed three main segments: informed consent, sociodemographic information, and KAP questions on COVID-19. Results The mean scores for knowledge, attitude, and practice were 4.05/6, 11.14/12, and 5.07/7, respectively. The results of the present study showed that year 1 respondents had significantly higher levels (p < 0.05) of KAP scores than year 4 respondents. In addition, the attitude score of science majors respondents was significantly greater (p < 0.05) than those of nonscience majors. The KAP scores showed no significant difference among groups with different sexes, ethnicities, and COVID-19 histories. Partial correlation analysis revealed that the overall knowledge score was positively correlated with attitude (r = 0.193, p = 0.001) and practice (r = 0.343, p < 0.001) scores whereas the total attitude score was positively correlated with the total practice score (r = 0.149, p = 0.010). Conclusion Our current results suggest that COVID-19 workshops, seminars, or training programs for year 4 students could be conducted to enhance their KAP levels.


Study design and respondents
This cross-sectional study was carried out using a snowball sampling technique in October 2021. The self-administered questionnaire was hosted on Google Forms, and the generated link was circulated to platforms such as Microsoft Teams, Facebook, Instagram, and WhatsApp. The minimum sample size, 264, was calculated using the Cochran formula with a prevalence rate of 22% [12], a margin of error of 5%, and a 95% confidence interval. A total of 299 Malaysian undergraduates were recruited after excluding those students who were in the foundation, diploma, and postgraduate studies. All respondents were required to log into their email accounts to participate in this survey. This is to prevent duplicate responses. To ensure the anonymity of respondents, the current study did not record any personal information. Ethical approval from the Universiti Tunku Abdul Rahman Scientific and Ethical Review Committee (protocol number: U/ SERC/181/2021) was obtained.

Survey instrument
The English version of the questionnaire encompassed three main segments: informed consent, sociodemographic information, and KAP questions on COVID-19. On the first page of the Google Form, the objectives, study background, eligible respondents' criteria, declaration of confidentiality and anonymity, and statements describing the willingness to participate as voluntary were made available. Respondents provided their consent by selecting 'agree' before participating in this study. Information on sex, ethnicity, year of study, field of study, and COVID-19 history were collected in the sociodemographic segment. Meanwhile, questions to assess the KAP towards COVID-19 were adapted from Ferdous 1 3 et al. [13]. The knowledge section comprised 6 items with the responses of yes, don't know, and no. Each correct answer was coded 1, whereas an incorrect or uncertain response was coded 0. The total knowledge score ranged from 0 to 6. Meanwhile, the attitude section comprised 6 items rated on a 3-point Likert scale (agree, undecided, and disagree). The total attitude score ranged from 0 to 12, with 0 points for 'disagree' , 1 point for 'undecided' , and 2 points for 'agree' for each response in this section. Last, the practice section comprised 7 items with the responses of yes, sometimes, and no. Each correct answer was coded 1, whereas an incorrect response was coded 0. The total practice score ranged from 0 to 7.

Statistical analysis
The data analysis was conducted using Microsoft Excel 2016 (Microsoft Corp., Redmond, WA, USA) and IBM Statistical Package for the Social Sciences (SPSS) software version 26 (IBM SPSS Statistics, Inc., Chicago, IL, USA). All data were sorted and coded in Microsoft Excel before importing into SPSS software. All quantitative variables were checked for normality and the variables with skewness in the range of ± 2 were considered normally distributed [14]. Descriptive data for categorical variables were reported as frequencies and percentages, whereas data for continuous variables were reported as the means and standard deviations (SD). The differences in the knowledge, attitude, and practice scores with the sociodemographic variables were examined using either an independent sample t test or a one-way analysis of variance followed by Tukey's post-hoc test. Demographics are potential confounder variables [15]. After controlling for factors that were statistically significant in the bivariate analysis, a partial correlation was used to understand the relationship between KAP scores. The level of significance was set at p < 0.05.

Sociodemographic characteristics
The sociodemographic characteristics of the respondents are summarized in Table 1. There were a total of 299 respondents (44.8% for males and 55.5% for females) recruited in this study. The majority of the respondents were Chinese (61.5%), year 3 (38.8%), science majors (51.8%), and without a COVID-19 history (82.9%).

Knowledge, attitudes, and practices towards COVID-19
The responses to the KAP questions are summarized in Table 2. More than 60% of the respondents agreed that COVID-19 was a dangerous disease, affected only human beings, and could be transmitted from human beings to animals and vice versa. Meanwhile, 58.2% of the respondents believed that COVID-19 can be transmitted in animal products, whereas 54.8% of the respondents viewed that COVID-19 can be transmitted in well-cooked products.
In the attitude components, more than 90% of the respondents answered that the suspected COVID-19 should be reported to health authorities, face masks should be worn when in a crowded place, hands and face should be washed after coming from outside, and COVID-19 cases can be reduced through health education. Meanwhile, 82.6% of the respondents believed that COVID-19 was a preventable disease, and 74.2% of the respondents viewed that COVID-19 can be treated at home.
Regarding practices, most of the respondents used tissues or handkerchiefs during coughing/sneezing (72.6%), washed hands frequently using water and soaps (78.9%), avoided touching the face and eyes (69.6%), maintained social distance or home quarantine (78.9%), ate healthy food (66.2%), maintained a healthy lifestyle (64.2%), and followed the government rules concerning COVID-19 (76.3%). Table 3 shows the differences in KAP scores according to the sociodemographic parameters. The overall scores for the knowledge, practice, and attitude components were 4.05 ± 1.90, 11.14 ± 1.29, and 5.07 ± 2.27, respectively. It was found that the attitude score of science majors respondents was significantly greater (p < 0.05) than those of nonscience majors. The KAP scores of year 1 respondents were significantly greater (p < 0.05) than those of year 4 respondents. The current study indicated no difference in the KAP scores between year 2 and year 3 respondents. However, the attitude and practice scores of year 4 respondents were significantly lower (p < 0.05) than those of year 2 and year 3 respondents. Other parameters, such as sex, ethnicity, and COVID-19 history exhibited no significant difference in the KAP scores.

Correlation between knowledge, attitude, and practice scores
The results of zero-order and partial correlations between KAP scores are shown in Table 4. Strengths of correlations are interpreted using the following criteria: > 0.90: very strong correlation, 0.70-0.89: strong correlation, 0.40 -0.69: moderate correlation, and < 0.39: weak correlation [16]. Sociodemographic variables that were statistically significant in the bivariate analysis (Table 3) were the controlled variables in partial correlation. The overall knowledge score exhibited weak, positive correlations with attitude (r = 0.193, p = 0.001) and practice (r = 0.343, p < 0.001) scores after controlling for field of study and year of study. Meanwhile, the total attitude score demonstrated a weak, positive correlation with the total practice score (r = 0.149, p = 0.010) after controlling for field of study and year of study. society to reduce the spreading rate of infection during pandemics and epidemics [24,34]. This is because the attitudes of an individual towards an infection is related to the knowledge level of that infection, and this will substantially influence the practices or preventative measures targeted at mitigating the infection. However, knowledge alone may not account for attitudes and practices towards COVID-19, as other factors, such as emotional state and risk perception, impact respondents' behavior and preventative measures [35]. This explains the weak interrelationship (r < 0.39) of the KAP in the present study. This is possibly the first study assessing the KAP toward COVID-19 among Malaysian undergraduates during emergency remote learning. Insights generated from this study are useful for institutions and policymakers to formulate effective strategies to enhance the KAP of virtual learning undergraduates towards COVID-19 before reverting teaching and learning to the physical mode. Meanwhile, the use of convenience sampling hinders the representativeness of the data at the study population level.

Conclusion
Teaching and learning in universities are conducted virtually during the COVID-19 outbreak. Accessing the KAP of COVID-19 among undergraduates is important before teaching and learning are reverted to the physical mode. Our study demonstrated that the total percentage scores of knowledge, attitude, and practice regarding COVID-19 among undergraduates were 67.5%, 92.8%, and 72.4%, respectively. This indicated that the respondents had good attitudes but moderate knowledge and practice levels toward COVID-19. Interventions focusing on raising the COVID-19 knowledge and practice levels of undergraduates are highly warranted. Funding This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability
The data that support the findings of this study are available upon email request from the corresponding author.

Competing interests
The authors declare no competing interests.
Ethics approval and consent to participate Approval from this study was obtained from the Universiti Tunku Abdul Rahman Scientific and Ethical Review Committee, with protocol number: U/SERC/181/2021. Informed consent to participate was obtained from all respondents involved in this study.

Competing interest All authors declare no conflicts of interest.
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